Havenwood Care Center: Medication Dosing Errors - MN
The resident, identified in inspection records only as R4, had been prescribed Baclofen for spasms. Her doctor increased part of her dose on August 28, and the pharmacy responded by sending a two-week supply in bubble packs, each containing the right number of tablets. Those ran out on September 20.
What happened next is what inspectors documented when they arrived on October 22.
When the bubble packs were gone, staff switched to a bottle of 10 mg Baclofen tablets that R4 had brought from home. The order calling for 30 mg doses, twice a day, was never reactivated to reflect that staff were now drawing from that bottle. The label on the bottle still said 20 mg, one and a half tablets, twice daily. Nobody reconciled the label against the order. Nobody caught that the math no longer worked. Staff began cutting the 10 mg tablets in half and administering those halves, delivering 10 mg where 30 mg had been ordered.
That continued from September 21 through October 22, the day of the inspection. Thirty-two days.
The problem surfaced not through any internal audit or nursing review, but because a medication aide, identified as TMA-A, came back from six weeks off work and went to pull R4's Baclofen. She noticed the bottle had no orange sticker, the kind the facility uses to flag that directions have changed and staff should refer to the electronic record instead. She looked closer. Inside the bottle were 73 whole pills and 5 half pills. She had put 3 half pills back into the bottle herself the day before, when she first returned. Now there were five. Someone had cut more tablets overnight.
The 10 mg tablets, she told inspectors, should never have been cut in half. There was no clinical reason to do it.
At 11:07 that morning, TMA-A printed an orange direction sticker herself and placed it over the written label on the bottle. She told the staff nurse what she had found, asked that the half pills be destroyed, and reported the situation to the director of nursing. A medication error report was filed.
The director of nursing confirmed the timeline to inspectors at 11:46 a.m. She walked through how the pharmacy bubble packs had covered the higher dose through September 20, how staff had then turned to the home medication bottle, and how the order had never been properly reactivated. The label said one thing. The order said another. Staff had been following neither correctly.
She said R4 had not reported increased pain that she was aware of.
The facility's own medication policy, dated December 2023, requires that labels on medicine bottles be neat and legible, and states that nurses may never re-label a medication themselves. If a label needs changing, the bottle goes back to the pharmacy, or a pharmacist comes in and applies a new label. The policy also requires that errors in dosage be reported immediately to an RN supervisor, with an incident report completed.
TMA-A did report the error the morning she found it. The 32 days before that, nobody did.
Inspectors also noted they requested the facility's medication cart safety policy during the investigation. It was never provided.
The federal violation was cited at a level of minimal harm or potential for actual harm, affecting a few residents. That designation reflects what inspectors could document, not necessarily what R4 experienced across more than a month of receiving half the medication her physician had ordered to control her spasms.
Whether her symptoms worsened during those 32 days, and whether anyone at the facility would have known if they had, the inspection report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Havenwood Care Center from 2025-10-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 29, 2026 · Our methodology
Havenwood Care Center in BEMIDJI, MN was cited for violations during a health inspection on October 22, 2025.
The resident, identified in inspection records only as R4, had been prescribed Baclofen for spasms.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.