Cokato Manor
COKATO MANOR in COKATO, MN — inspection on June 10, 2026.
Found 2 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
reviewed, and revised by a team of health professionals.
interview and document review, the facility failed to provide routine care conferences to allow for
quarterly minimum data set (MDS) assessment dated [DATE], indicated R40 was admitted to the facility on [DATE], was cognitively intact and had the following diagnoses: high blood pressure, arthritis, and schizophrenia.R40's electronic medical record (EMR) revealed documentation of care conferences being held on 5/2/25, 10/7/25, 12/30/25, and 3/28/26.
The EMR lacked evidence of a care conference being held between 5/2/25 and 10/7/25.
During an interview on 6/8/26 at 9:10 a.m., R40 stated she understood what care conferences were but had not been invited to any type of care meeting over the past year.During interview on 6/10/26 at 2:38 p.m., Licensed Social Worker (LSW) stated care conferences should be held at time of admission, then every three months and/or if there was a significant change of condition. LSW collaborated with other team members to gather pertinent care plan information. It was reviewed with the resident and their representative at the care conference. LSW stated she was responsible for scheduling and documenting care conferences in the EMR (electronic medical record). LSW could not provide documentation of a care conference being held between 5/2/25 and 10/7/25 and stated, If it isn't documented it didn't happen. LSW stated it was important to have quarterly care conferences with the residents because they were the foundation of the care and residents had the right to be included in decisions that directly affect their care.During interview on 6/10/26 at 2:53 p.m., Administrator (Admin) stated care conferences were offered and held with the MDS quarterly schedule and as needed for a significant change of condition.
Admin stated LSW was responsible for scheduling and documentation of care conferences for all residents.
Admin stated when a care conference was held there should be a follow-up note in the EMR documenting the outcome of the meeting.
Admin confirmed there was no documentation for a care conference being held for R40 between 5/2/25 and 10/7/25.
Admin stated she expected care conferences to be held quarterly and should include the residents if they were able or their representative.
Admin stated it was important to have quarterly care conferences so the residents can be involved in the planning of their care.A facility policy titled Cokato Manor Interdisciplinary Care Planning with a last review date of 2/2026 indicated the following: The residents and their designated responsible party are invited to attend the initial care planning conference and sequential conferences: annual and significant change conferences.
Social worker to be responsible for leading the care conference meeting with the interdisciplinary team, resident and responsible party.
Residents and families are invited to care planning meetings by the social worker.
The social worker informs families of time constraints and monitors time during the care planning session.
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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
245412 06/10/2026
Cokato Manor 182 Sunset Avenue Cokato, MN 55321
Based on observation, interview, and document review, the facility failed to ensure medications were
in 2 of 2 medications carts and 1 of 1 medication rooms reviewed for medication labeling and storage.
Findings include:During observation and interview on 6/10/26 at 9:06 a.m., with registered nurse (RN)-A the North medication cart was reviewed and revealed the following:Nizoral shampoo- dated 9/10/24 (exp date:1/2026)Victosa insulin pen: no opened-on dateDiclofenec Sod Top Gel: no opened-on dateBiofreeze gel 4%: no opened-on date Hydrocortison cream 1%: no opened-on dateBiofreeze 4% gel: no opened-on dateNystatin cream100000 u: no opened-on dateDiclofenec gel: no opened-on dateHemorrhoidal ointment: no opened-on dateCalmoseptine ointment: dispensed 10/11/24; No opened-on dateDiclofenca Sod Top Gel 1%: no opened-on dateDiclofenca Sod Top Gel 1%: no opened-on dateTriamcinolone Acetonide Cream (2 15-gram tubes): no opened-on dateRN-A stated all eyedrops, creams, gels or anything that comes in a tube should be dated as soon as it is opened.
RN-A stated all nurses and trained medication aides (TMA's) should be checking for an opened-on date when using these medications.
During observation and interview on 6/10/26 at 9:31 a.m., the medication room was reviewed with RN-A and revealed the following opened medications:Sustane eye drops (2 bottles): no opened-on dateKetoconazole cream 2%: no opened-on datesBacitracin ointment: no opened-on dateHydrocortisone cream 2.5%: sticker indicated dispensed on 4/23/24 -to be discarded 4/23/25- no opened-on dateDorzolamide Hydrochloride and Timolol Maleate Ophthalmic Solution 2% (2 bottles): no opened-on date During observation and interview on 6/10/26 at 10:03 a.m., with RN-B the East wing medication cart was reviewed and revealed the following:Hydrocortisone Cream 1%- no opened-on dateDiclofenac Sodium Gel 1%: no opened-on dateRN-B stated if a medication was missing the opened-on date it shouldn't be used because it could be expired, and the resident wouldn't get the actual prescribed dose.
During interview on 6/10/26 at 3:01 p.m., Director of Nursing (DON) stated all medications should have an opened-on date clearly affixed so staff can identify when a medication was opened. DON stated she expected staff to affix an opened-on sticker and fill it out each time they opened a new bottle of eyedrops, creams, gels etc. DON went on to state staff should be checking this date every time they administer these medications. DON stated it was important to have the opened-on date because without it staff could inadvertently administer expired medications which would be less effective or ineffective.
Facility policy titled Medication Storage in The Facility with a last review date of 2/26 indicated the following: When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated; The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration.
The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating.
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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.