Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
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 Marian Manor Healthcare Center during CMS and state inspections, most recent first.
A resident with dementia, cleft palate, and dysphagia was ordered an IDDSI Level 6 soft and bite-sized diet, but marshmallows were left in the room and later eaten, leading to a choking episode with cyanosis, pulselessness, apnea, and hospitalization. Staff also served a meal tray with a whole Salisbury steak patty and other foods not prepared into bite-sized pieces, and interviews showed staff were not consistently educated on the resident’s diet restrictions or IDDSI requirements.
Medication Labeling and Preparation Errors: A nurse prepared a resident’s Humalog insulin pen without an open and discard date, and in a separate observation, pre-dished oral meds for several residents and left them on the med cart before administration. Facility policy required insulin pens to be labeled with open and discard dates and medications to be administered as soon as possible after preparation.
A facility's QAPI committee did not develop a PIP to address a choking incident involving a resident with dysphagia on a Level 6 soft and bite-sized diet. Staff confirmed the resident ate regular-sized marshmallows kept in the room, and the resident was later found on the floor with marshmallow-like material removed during suctioning. The facility's QAPI process had monitored food temperatures but not diet accuracy, and the dietary QAPI process did not include diet accuracy.
Choking Episode After Inappropriate Foods Were Left and Served to a Resident on a Soft and Bite-Sized Diet
Penalty
Summary
The facility failed to provide appropriate supervision for a resident with an ordered mechanically altered diet when snack items not consistent with that diet were left in the resident’s room. The resident had diagnoses including dementia, cleft palate, and dysphagia, and speech therapy had recommended an IDDSI Level 6 soft and bite-sized diet. The care plan identified the resident as being at risk for aspiration and choking and specified mechanically altered consistency, Level 6 soft and bite-sized. On the day of the incident, staff found the resident after a loud thump and observed him face down on the floor with blood present and his color purple from the head to the upper limbs. A nurse documented that marshmallows were coming out of the resident’s mouth and nose and that suctioning was performed. The resident’s record and hospital documentation stated he had been eating marshmallows when he became pulseless, apneic, and cyanotic, and he was admitted after a choking-related event with aspiration pneumonia and oxygen needs. The facility investigation stated the resident had been snacking on a bag of marshmallows that had been brought in by his sister and left on his over-the-bed table. The investigation and interviews showed staff did not ensure foods served or available to the resident matched the ordered diet. Administrative nurses stated the marshmallows were not bite-sized and that staff were not really educated on mechanically altered diets and IDDSI levels. The CNA involved stated the nurse was in charge of knowing what the resident could or could not have. During a later meal observation, a CNA delivered a tray to the resident that included a whole Salisbury steak patty and baked apples cut into approximately 1-inch pieces, and the CNA left without cutting the meat into bite-sized pieces. The dietary supervisor stated kitchen staff did not cut food into bite-sized pieces before meals left the kitchen, and the dietician and speech language pathologist confirmed that marshmallows were not appropriate and that meat patties should be cut into bite-sized pieces for this diet.
Medication Labeling and Preparation Errors
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications for 2 of 9 observations of medication preparation and administration. During observation, a staff nurse prepared Resident #25’s Humalog insulin pen for administration and obtained the pen from a plastic bag labeled with the resident’s name, but the pen did not have an open and discard date. Facility policy stated that insulins are to be labeled with open and discard dates and disposed of 28 days after opening unless otherwise specified by the manufacturer. In a separate observation, three medication cups containing oral medications, each labeled with resident first names, were left on top of the medication cart while a nurse prepared a fourth cup. When asked about the practice, the nurse stated she had prepared 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. Facility policy stated that drugs are to be administered as soon as possible after doses are prepared and that medications should not be pre-dished for future medication passes. An administrative nurse later confirmed staff should label insulin pens with an open and discard date and should not pre-dish medications.
QAPI Failed to Address Diet Accuracy After Choking Incident
Penalty
Summary
The facility's QAPI committee failed to develop a Performance Improvement Project to decrease or prevent adverse events and ensure compliance with federal requirements related to a resident choking incident. The facility's QAPI plan stated that PIPs are used to examine and improve care or services in specifically identified areas, but during interviews an administrative nurse stated that QAPI had previously monitored food temperatures and not the accuracy of diets served to residents, and a dietary supervisor confirmed the dietary QAPI process did not include diet accuracy. The choking incident involved a resident with dysphagia who was on a mechanically altered diet, Level 6 soft and bite-sized, and was at risk for aspiration and choking. The facility investigation stated the resident had been eating lunch and had a bag of marshmallows on the over-bed table, which he had been snacking on before lunch. Staff later heard a loud crash and found him prone on the floor next to his wheelchair; suctioning was performed and small white pieces of material that looked like marshmallow were removed. Surveyor review and staff interview confirmed the resident ate regular-sized marshmallows, and the State Survey Agency determined the incident resulted in an Immediate Jeopardy when staff failed to remove snack items not consistent with the resident's diet order from the room.
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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 Glen Ullin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elm Crest Manor | 18.2 mi | ★★★★★ | 3 | 0 |
| Richardton Health Center Inc | 24.1 mi | ★★★★★ | 3 | 0 |
| Knife River Care Center | 32.6 mi | ★★★★★ | 1 | 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.