Marian Manor Healthcare Center
MARIAN MANOR HEALTHCARE CENTER in GLEN ULLIN, ND — inspection on June 3, 2026.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During interviews on 05/26/26 at 1:30 p.m. and 05/27/26 at
jeopardy to resident health or Resident #3 stated, Peas, steak, and nuts.
When asked specifically about marshmallows, the resident safety stated, Marshmallows are a dirty word and The last time I took a bite of a marshmallow I passed out.
During a telephone interview on 05/27/26 at 1:20 p.m., Resident #3's representative identified
with a list of restricted foods.
She stated the facility informed her about the marshmallows brought in by the sister after the 02/17/26 incident.
The representative verified the sister's current awareness of the marshmallow restriction.During a telephone interview on 05/27/26 at 2:31 p.m., a dietician (#7) confirmed she expected facility staff to cut the Salisbury steak into bite-sized pieces before delivery to residents with an order for soft and bite-sized food.
During a telephone interview on 05/28/26 at 11:05 a.m., a speech language pathologist (#8) confirmed marshmallows are not appropriate for an ordered IDDSI level 6 soft and bite-sized diet, and she expected staff to cut meat patties into bite sized pieces for a resident with an order for IDDSI level 6 soft and bite-sized food.
The facility failed to ensure the resident, resident representative, and staff understood appropriate food choices for Resident #3's ordered diet, and staff followed Resident #3's ordered diet.2.
Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide adequate supervision and assistive devices for 1 of 4 sampled residents (Resident #3) observed during a transfer.
Failure to use a gait belt and the appropriate number of staff during transfers placed all residents at risk for accidents, falls, or injuries.Findings include:
Review of the facility policy titled Transferring Resident with Transfer (Gait) Belt occurred on 05/28/26.
This policy, dated March 2025, stated, . It is the policy of this facility to use a gait/transfer belt to guide and support residents who: .
May require assistance with a transfer due to the resident being unsteady and having the potential to fall .
Place the transfer/gait belt around resident's waist .
Refer to ADLs [activities of daily living] and use one or two staff members with transfer as careplanned [sic] for safety of resident and staff.Review of Resident #3's medical record occurred on all days of survey.
Diagnoses included dizziness, weakness, syncope, and orthostatic hypotension (sudden drop in blood pressure when moving from lying/sitting to standing).
The current care plan stated, . I have a Potential for Trauma-Falls . ADL door card is part of the care plan . provide assistance with ambulation, transfers, and assistive devices as per current ADL's .
The ADL door card stated, .
Transfers . recommend partial/moderate assist to pivot x2 [times two staff] with gait belt .Observation on 05/27/26 at 11:03 a.m. showed Resident #3 resting in bed. A certified nurse aide (CNA) (#3) entered the resident's room and assisted Resident #3 to stand and pivot to the wheelchair.
The CNA failed to apply the gait belt and utilize a second staff member for the transfer.Observation on 05/28/26 at 9:35 a.m. showed Resident #3 seated in a shower chair with a gait belt around the waist.
The resident held onto the assist bar on the wall and stood. A CNA (#5) placed the wheelchair behind the resident and the resident sat in the wheelchair.
When asked if the CNA assisted the resident to transfer from the bed to the wheelchair alone prior to the bath, the CNA stated, Yes [Resident #3] is a one-person transfer.
During an interview on 05/28/26 at 10:14 a.m. an administrative nurse (#1) confirmed Resident #3's care plan identified assist of two staff for transfers.
355036 06/03/2026
Marian Manor Healthcare Center 604 Ash Ave E Glen Ullin, ND 58631
Based on observation, review of facility policy, and staff interview, the facility failed to ensure proper
administration.
Failure to date an insulin pen with the open and discard date and failure to ensure medications are administered promptly after preparation may result in an ineffective dose of insulin and medication errors.
Findings include:
Review of the facility policy titled Medication Disposal occurred on 05/28/26.
This undated policy stated, .
Insulins are disposed of 28 days from the date opened unless otherwise specified by the manufacturer.
These will be labeled with open and discard dates.
Review of the facility policy titled Administration of Drugs occurred on 05/28/26.
This undated policy stated, .
Drugs are to be administered as soon as possible after doses are prepared.
Medications should not be pre-dished for future medication passes.-Observation on 05/26/2026 at 5:05 p.m. showed a staff nurse (#9) prepared Resident #25's Humalog insulin pen for administration.
The nurse obtained the pen from a plastic bag labeled with the resident's name.
The pen lacked an open and discard date. -Observation on 05/26/26 at 5:25 p.m. showed three medication cups containing oral medication, labeled with resident first names, on top of the medication cart. A nurse (#9) prepared a fourth medication cup and labeled it with the resident's first name.
When asked about pre-dishing the medications, the nurse (#9) stated she prepared the supper medications for a few residents so she could help feed residents in the dining room and would administer the medications to those four residents at that time.
During an interview on 05/28/2026 at 10:59 a.m., an administrative nurse (#1) confirmed staff should label insulin pens with an open and discard date and confirmed staff should not pre-dish medications.
355036 06/03/2026
Marian Manor Healthcare Center 604 Ash Ave E Glen Ullin, ND 58631
Review of Resident #3's current care plan stated, . I have a dx [diagnosis] of Dysphagia . I am at risk of aspiration [breathing food, liquid, saliva, or vomit into airway and lungs] and choking .
Mechanically altered consistency .
Level 6 soft and bite sized .
During the survey team's investigation, interview on 05/26/26 at 4:10 p.m. two administrative nurses (#1 and #2). confirmed Resident #3 ate regular sized marshmallows (not miniature sized) on the day of the choking incident.After reviewing Resident #3's choking incident, the survey team consulted with the State Survey Agency (SSA) and it was determined an immediate jeopardy (IJ) situation existed on 02/17/26 at 11:30 a.m.
The IJ resulted when staff failed to remove snack items not consistent with Resident #3's mechanically altered diet order from the resident's room which resulted in Resident #3 experiencing a choking episode and hospitalization.
During an interview on 05/28/26 at 11:10 a.m., an administrative nurse (#2) stated in the past, QAPI monitored food temperatures, but not the accuracy of diets served to residents.
During an interview on 05/28/26 at 11:48 a.m., a dietary supervisor (#6) confirmed the dietary QAPI process did not include diet accuracy.Refer to F-F689.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.