Above 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 Cokato Manor during CMS and state inspections, most recent first.
Missed Quarterly Care Conference and Resident Participation: A resident who was cognitively intact and had HTN, arthritis, and schizophrenia did not have documented routine care conferences at the expected quarterly interval. The EMR showed care conferences were documented, but there was no evidence of one between two documented meetings, and the resident stated she had not been invited to any care meetings over the past year. The LSW and Admin both confirmed the lack of documentation and stated residents should be included when able.
Medications in two med carts and one med room were found without opened-on dates, including eyedrops, creams, gels, ointments, and an insulin pen. RN-A and RN-B stated these items should be dated when opened, and the DON confirmed staff were expected to affix and complete date-opened stickers for these medications. Facility policy required containers or vials to be dated when the original seal was broken.
The facility did not ensure that residents or their representatives were included in care conferences or consulted before changes were made to care plans. Multiple residents with severe cognitive impairment and complex medical conditions had care plan summaries completed by staff without documented input from the residents or their families. Family members reported not being informed or included in care planning discussions, and staff confirmed that care plan summaries were sent to families only after revisions were made, without prior engagement.
A resident's advance directive indicating Do Not Resuscitate (DNR) was not consistently documented across the medical record, with the signed DNR form conflicting with physician orders in the EMR that listed the resident as FULL CODE. Staff relied on multiple sources to verify code status, and the DON confirmed the inconsistency, which did not align with the facility's policy requiring accurate reflection of resident wishes.
A resident with severe cognitive impairment and psychiatric diagnoses experienced an increase in involuntary movements, as indicated by a higher AIMS score after receiving escalating doses of quetiapine. Despite this change, there was no documentation that the physician was notified, as confirmed by interviews with the consulting pharmacist and DON. The facility could not provide a relevant policy, and the clinical record lacked evidence of required physician notification.
A resident admitted with schizophrenia, arthritis, and diabetes did not have a required Level II PASARR completed, despite a Level I PASARR indicating it was necessary. The social services director used documentation from a previous facility and was unaware of the need for a Level II PASARR until notified by surveyors. No related facility policy was available.
A resident with severe cognitive impairment and a history of multiple falls did not have a comprehensive or regularly updated care plan to address fall prevention. Despite numerous falls, the care plan contained limited interventions, and staff were unaware of specific fall prevention measures. Observations showed the resident was left unsupervised with safety risks present, and facility policy requiring timely care plan updates was not followed.
A resident with severe cognitive impairment and behavioral symptoms received PRN lorazepam on several occasions without evidence that non-pharmacological interventions were attempted or documented beforehand, despite care plan requirements and staff expectations. Facility records and behavior monitoring logs lacked documentation of both the target behaviors and the interventions used prior to medication administration.
A resident with severe cognitive impairment and multiple psychiatric diagnoses was prescribed psychotropic medications, but target behavior monitoring was inconsistently documented and absent for several months. The consulting pharmacist conducted monthly medication regimen reviews but failed to identify or address the lack of behavior monitoring, despite facility policy and expectations for such oversight.
The facility did not hold QAPI meetings at least quarterly as required, with documentation and staff interview confirming that meetings were not conducted at the mandated frequency.
A trained medication aide was observed administering medications to three residents without performing hand hygiene before, after, or between each medication pass. The aide later acknowledged the lapse, and the DON confirmed that facility policy requires hand hygiene at these times to prevent infection.
A resident with a history of Parkinson's disease, dementia, and an indwelling urinary catheter was prescribed antibiotics for a UTI, but the facility did not ensure the prescription met established criteria or assess the continued need for antibiotics. Nursing staff did not document review of urine culture results or notify the provider when sensitivities were not received, and a 72-hour antibiotic time-out was not completed as required by the facility's stewardship policy.
Missed Quarterly Care Conference and Resident Participation
Penalty
Summary
The facility failed to provide routine care conferences to allow resident participation for one resident who was reviewed for care conferences. The resident’s quarterly MDS assessment indicated admission to the facility, cognitive intactness, and diagnoses of high blood pressure, arthritis, and schizophrenia. The resident’s EMR showed care conferences were documented on 5/2/25, 10/7/25, 12/30/25, and 3/28/26, but there was no evidence of a care conference between 5/2/25 and 10/7/25. During interview, the resident stated she understood what care conferences were but had not been invited to any type of care meeting over the past year. The LSW stated care conferences should occur at admission, then every three months and/or with a significant change of condition, and that she was responsible for scheduling and documenting them in the EMR. The LSW could not provide documentation of a care conference between 5/2/25 and 10/7/25 and stated, "If it isn't documented it didn't happen." The Administrator confirmed care conferences were expected quarterly and should include residents if able or their representative, and also confirmed there was no documentation of a care conference for the resident during that interval. The facility policy stated residents and their designated responsible party are invited to attend the initial care planning conference and sequential conferences, including annual and significant change conferences.
Medications Missing Opened-On Dates
Penalty
Summary
The facility failed to ensure medications were appropriately labeled with an opened-on date in 2 of 2 medication carts and 1 of 1 medication rooms reviewed for medication labeling and storage. During observation and interview, the North medication cart contained multiple medications without opened-on dates, including Nizoral shampoo, Victosa insulin pen, Diclofenec Sod Top Gel, Biofreeze gel 4%, Hydrocortison cream 1%, Nystatin cream, Hemorrhoidal ointment, Calmoseptine ointment, Diclofenca Sod Top Gel 1%, and Triamcinolone Acetonide Cream. RN-A stated that all eyedrops, creams, gels, and similar medications in tubes should be dated as soon as they are opened, and that nurses and TMAs should check for an opened-on date when using these medications. The medication room also contained opened medications without opened-on dates, including Sustane eye drops, Ketoconazole cream 2%, Bacitracin ointment, Hydrocortisone cream 2.5%, and Dorzolamide Hydrochloride and Timolol Maleate Ophthalmic Solution 2%. In the East wing medication cart, Hydrocortisone Cream 1% and Diclofenac Sodium Gel 1% were also missing opened-on dates. RN-B stated that if a medication was missing the opened-on date it should not be used because it could be expired and the resident would not get the actual prescribed dose. The DON stated all medications should have an opened-on date clearly affixed and that staff should place an opened-on sticker and fill it out each time a new bottle of eyedrops, creams, gels, or similar medications was opened. Facility policy stated that when the original seal is broken, the container or vial will be dated and the nurse shall place a date-opened sticker and enter the date opened and new expiration date.
Failure to Involve Residents or Representatives in Care Conferences
Penalty
Summary
The facility failed to ensure that care conferences included the input of residents or their representatives for five residents who were reviewed for care conferences. Each of these residents was identified as being severely cognitively impaired, with diagnoses including dementia, Alzheimer's disease, hypertension, arthritis, seizure disorder, Parkinson's disease, heart failure, and hemiparesis or hemiplegia. Despite their cognitive impairments, there was no documentation in the medical records that the residents, their representatives, or family members had been contacted prior to care conferences or the implementation of changes to their care plans. Care plan summaries for these residents showed input from nursing, social services, and dietary staff, but consistently lacked any indication of involvement from the resident, their representative, or family members. Interviews with facility staff revealed that the social services director was responsible for care conferences and typically sent out care plan summaries to staff for input, then mailed the completed summary to families for review. If families did not respond or request a meeting, no in-person care conference was conducted, and one-to-one meetings with residents occurred only after care plan revisions. Family members confirmed they had not been made aware of or included in care conferences, nor asked to provide input regarding treatment and services. The facility's own policy required that care plans be reviewed at a care planning meeting with the resident and/or representative, and a summary shared with them. However, the process in practice did not ensure resident or representative participation prior to care plan changes, as evidenced by the lack of documentation and family reports of not being included. The administrator acknowledged the need for a process change to involve families more in guiding care, confirming that the current approach did not meet expectations for resident and family involvement.
Inconsistent Documentation of Advance Directives for Emergency Treatment
Penalty
Summary
The facility failed to ensure that a resident's advance directives for emergency treatment were consistently and accurately reflected across all areas of the medical record. Specifically, for one resident who was cognitively intact and had diagnoses including hyperlipidemia and schizophrenia, there was a discrepancy between the documented code status in different parts of the medical record. The resident's signed code status form, which was also signed by a family member and physician, indicated a Do Not Resuscitate (DNR) order. However, the physician orders in the electronic medical record (EMR) listed the resident as FULL CODE. Interviews with facility staff, including a trained medical assistant, a registered nurse, and the director of nursing (DON), revealed that staff relied on various sources such as the hard chart, face sheet, and medication administration record (MAR) to determine code status. The DON confirmed that the resident's wishes were not consistently documented, as the physician orders did not match the signed DNR form. The facility's policy required that emergency care, including CPR, be provided according to physician orders and resident choice as indicated in advance directives, but this was not accurately implemented in this case.
Failure to Notify Physician of Change in Condition Following Increased AIMS Score
Penalty
Summary
The facility failed to notify the attending physician of a significant change in condition for a resident with severe cognitive impairment and multiple psychiatric diagnoses, including Alzheimer's disease, delusional disorders, and anxiety disorder. The resident was prescribed increasing doses of quetiapine, an antipsychotic medication, over several months. An initial Abnormal Involuntary Movement Scale (AIMS) assessment showed no involuntary movements, but a follow-up assessment revealed a notable increase in symptoms, with the AIMS score rising from 0 to 4. Despite this documented change, there was no evidence in the clinical record that the physician had been notified of the new onset of tardive dyskinesia symptoms. Interviews with the consulting pharmacist and the director of nursing confirmed that changes in AIMS scores should be communicated to the provider, and that nurses are expected to document such notifications in the clinical record. Both the pharmacist and DON emphasized the importance of notifying the physician to ensure resident safety and appropriate medication management. The facility was unable to provide a policy regarding this process, and the clinical record lacked documentation of physician notification following the resident's increased AIMS score.
Failure to Complete Required Level II PASARR Screening
Penalty
Summary
The facility failed to ensure that a Level II Pre-Admission Screening and Resident Review (PASARR) was completed for one resident who was admitted with diagnoses including schizophrenia, arthritis, and diabetes. Documentation showed that a Level I PASARR was completed prior to admission, which indicated the need for a Level II PASARR, but no evidence of a completed Level II PASARR was found. The social services director confirmed that they relied on the PASARR from the resident's previous facility and were unaware that a Level II PASARR was required until informed by the survey team. The administrator stated that PASARR screenings were expected to be completed by social services or delegated staff upon admission. No facility policy related to PASARR was provided when requested.
Failure to Update and Implement Comprehensive Fall Prevention Care Plan
Penalty
Summary
The facility failed to develop and maintain a comprehensive care plan with appropriate interventions to prevent falls or reduce the likelihood of injury for a resident with a history of multiple falls. The resident, who had severe cognitive impairment, osteoarthritis, weakness, and mixed incontinence, was identified as being at high risk for falls. Despite having 23 documented falls over a six-month period, the care plan was not updated after each incident and contained limited interventions. Observations revealed that the resident's call light was frequently out of reach, wheelchair brakes were unlocked, and the resident was left unsupervised while attempting to reach for objects, all of which increased the risk of falls. Interviews with CNAs indicated a lack of awareness regarding specific fall interventions for the resident, and staff were unable to identify or locate the interventions in the care plan. The DON confirmed that the care plan had not been updated as required and acknowledged the importance of keeping care plans current to ensure resident safety. Facility policy required care plans to be updated quarterly and as needed, reflecting close evaluation of problems, goals, and approaches, but this was not followed in the resident's case.
Failure to Attempt and Document Non-Pharmacological Interventions Before PRN Psychotropic Use
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted and documented prior to the administration of PRN psychotropic medications for a resident with severe cognitive impairment and behavioral symptoms. The resident, who had diagnoses including dementia, delusional disorders, and depression, had a care plan that included non-pharmacological approaches such as reassurance, encouraging activities of choice, 1:1 visits, and redirection. Despite these care plan interventions, documentation showed that lorazepam was administered on multiple occasions for behavior issues or other reasons, but there was no evidence in the clinical record or behavior monitoring logs that non-pharmacological interventions were attempted before medication was given. The facility's records, including the Medication Administration Record and Target Behavior Monitoring logs, lacked documentation of target behavior episodes and management interventions for the relevant dates when the PRN psychotropic was administered. Interviews with the consulting pharmacist and the DON confirmed that non-pharmacological interventions should have been attempted and documented prior to administering PRN psychotropics, except in severe situations. The facility was unable to provide a policy regarding this practice when requested.
Failure to Identify Lack of Target Behavior Monitoring in Psychotropic Medication Review
Penalty
Summary
The facility failed to ensure that the consulting pharmacist identified the lack of target behavior monitoring for a resident receiving psychotropic medications during the monthly medication regimen review (MRR). The resident, who had severe cognitive impairment and diagnoses including Alzheimer's disease, delusional disorders, and anxiety disorder, was prescribed paroxetine for panic disorder and quetiapine for delusional disorders. Documentation showed that target behaviors such as anxiety, agitation, and depression were only monitored for 8 out of 45 shifts in one month, and there was no evidence of target behavior monitoring in the clinical record for several months. Despite multiple monthly reviews by the pharmacist, the absence of consistent target behavior monitoring was not identified or addressed in the MRRs. The pharmacist's notes included recommendations for gradual dose reduction and monitoring for side effects, but did not note the lack of behavior monitoring. Both the pharmacist and the DON confirmed that target behavior monitoring is expected when psychotropic medications are prescribed, and the facility's policy requires the pharmacist to address irregularities during the MRR. However, this expectation was not met for the resident in question.
Failure to Hold QAPI Meetings Quarterly
Penalty
Summary
The facility failed to ensure that Quality Assurance Performance Improvement (QAPI) meetings were held on a quarterly basis as required. Document review showed that QAPI meetings occurred on 4/16/24, 8/27/24, and 1/7/25, which did not meet the minimum frequency of every three months or quarterly. During an interview, the director of nursing, who leads the QAPI meetings, confirmed that the facility had not been meeting the required schedule and acknowledged that an additional meeting should have been held to maintain compliance. The facility's own QAPI plan, effective 1/2025, specifies that the committee is responsible for meeting at least quarterly.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
A trained medication aide (TMA) was observed administering medications to multiple residents without performing appropriate hand hygiene before, after, or between resident contacts. The TMA prepared and administered medications to three different residents consecutively, failing to wash or sanitize hands at any point during the process, including after completing all medication administrations. The TMA later acknowledged the failure to perform hand hygiene and recognized its importance in preventing the spread of infection. During the observation, another staff member, an LPN, was present and the TMA requested assistance. The director of nursing (DON) confirmed that facility policy requires staff to perform hand hygiene before and after all medication administrations and between residents. The facility's hand washing/hygiene policy, last revised in February 2024, specifies that hand washing must be completed between resident care and whenever direct physical contact with a resident occurs.
Failure to Follow Antibiotic Stewardship Protocols for UTI Treatment
Penalty
Summary
The facility failed to ensure that prescribed antibiotics met established criteria for use and did not adequately assess the continued need for antibiotics for a resident with a urinary tract infection (UTI). The resident, who was cognitively intact and had an indwelling urinary catheter along with diagnoses of Parkinson's disease, dementia, and obstructive uropathy, was prescribed cefpodoxime after completing a previous course of Macrobid without improvement. The provider ordered a urinalysis and urine culture, with instructions to update the antibiotic based on culture and sensitivity results. However, the urine culture indicated likely contamination, and there was no evidence that the culture and sensitivity results were reviewed by nursing staff or that the provider was notified when sensitivities were not received. The clinical record lacked documentation that antibiotic stewardship guidelines were followed, including the completion of a 72-hour antibiotic time-out and review of the appropriateness of continued antibiotic therapy. The facility's infection preventionist confirmed that these steps were not completed and acknowledged that the antibiotic stewardship policy, which requires regular review of antimicrobial therapy, was not adhered to in this case.
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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 Cokato
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakeside Generations Health Care Center | 5.1 mi | ★★★★★ | 5 | 0 |
| Good Samaritan Society - Howard Lake | 5.9 mi | ★★★★★ | 10 | 0 |
| The Gardens At Winsted Llc | 10.5 mi | ★★★★★ | 6 | 0 |
| Annandale Care Center Inc | 13.4 mi | ★★★★★ | 1 | 0 |
| Meeker Manor Rehabilitation Center, Llc | 15.8 mi | ★★★★★ | 15 | 0 |
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