Cokato Manor

Inspection findings

1. Jun 10, 2026 Health · 5 findings
   • Not serious Scope/severity D

     F0657 Resident Assessment and Care Planning Deficiencies

     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

     Corrected Jul 10, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Jul 10, 2026 · CMS health inspection

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Jul 3, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jul 15, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0921 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure that testing and maintenance of electrical equipment is performed.

     Corrected Jul 3, 2026 · CMS fire safety

2. Apr 25, 2025 Health · 18 findings
   • Not serious Scope/severity D

     F0578 Resident Rights Deficiencies

     Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

     Corrected Jun 20, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Jun 20, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0644 Resident Assessment and Care Planning Deficiencies

     Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

     Corrected Jun 20, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Jun 20, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0657 Resident Assessment and Care Planning Deficiencies

     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

     Corrected Jun 20, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0741 Quality of Life and Care Deficiencies

     Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.

     Corrected Jun 20, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0756 Pharmacy Service Deficiencies

     Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

     Corrected Jun 20, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0758 Pharmacy Service Deficiencies

     Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

     Corrected Jun 20, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0868 Administration Deficiencies

     Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

     Corrected Jun 20, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jun 20, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0881 Infection Control Deficiencies

     Implement a program that monitors antibiotic use.

     Corrected Jun 20, 2025 · CMS health inspection

   • Not serious Scope/severity F

     K0291 Egress Deficiencies

     Install emergency lighting that can last at least 1 1/2 hours.

     Corrected May 22, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected May 22, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected May 22, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected May 22, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0914 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

     Corrected May 22, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected May 22, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0926 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.

     Corrected May 22, 2025 · CMS fire safety

3. Feb 14, 2024 Fire Safety · 9 findings
   • Not serious Scope/severity F

     E0041 Emergency Preparedness Deficiencies

     Implement emergency and standby power systems.

     Corrected Mar 1, 2024 · CMS fire safety

   • Not serious Scope/severity D

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Mar 1, 2024 · CMS health inspection

   • Not serious Scope/severity C

     F0565 Resident Rights Deficiencies

     Honor the resident's right to organize and participate in resident/family groups in the facility.

     Corrected Mar 1, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0604 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

     Corrected Mar 1, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0623 Resident Rights Deficiencies

     Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

     Corrected Mar 1, 2024 · CMS health inspection

   • Not serious Scope/severity C

     F0732 Nursing and Physician Services Deficiencies

     Post nurse staffing information every day.

     Corrected Mar 1, 2024 · CMS health inspection

   • Not serious Scope/severity D

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Mar 6, 2024 · CMS fire safety

   • Not serious Scope/severity C

     K0901 Electrical Deficiencies

     Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.

     Corrected Mar 1, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Mar 1, 2024 · CMS fire safety

4. Jun 23, 2022 MDH complaint investigation · 1 finding
   • Severity not stated

     H54122106C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

Owners and managers (as published by CMS)

• ANDERSON, ALLAN — corporate director, NOT APPLICABLE, since 07/20/1990
• BORTNEM, PETER — corporate director, NOT APPLICABLE, since 10/01/2013
• CARLSON, JESSE — corporate director, NOT APPLICABLE, since 09/01/2021
• CARLSON, PEGGY — corporate director, NOT APPLICABLE, since 06/01/1996
• CATES, SHAY — w-2 managing employee, NOT APPLICABLE, since 06/20/2000
• DIXON, BRIAN — contracted managing employee, NOT APPLICABLE, since 12/06/2016
• DIXON, BRIAN — adp of the snf, NOT APPLICABLE, since 01/02/2025
• HANSON, STEVEN — corporate director, NOT APPLICABLE, since 07/20/1990
• KEITH, KATE — corporate director, NOT APPLICABLE, since 01/01/2023
• LUHMAN, CINDY — corporate director, NOT APPLICABLE, since 09/01/2021
• MELQUIST, TRESHA — corporate director, NOT APPLICABLE, since 02/08/2021
• MELQUIST, TRESHA — corporate officer, NOT APPLICABLE, since 02/08/2021
• MELQUIST, TRESHA — w-2 managing employee, NOT APPLICABLE, since 02/08/2021
• MELQUIST, TRESHA — adp of the snf, NOT APPLICABLE, since 01/02/2025
• SVELA, DEAN — corporate director, NOT APPLICABLE, since 09/01/2021