Havenwood Care Center: Wrong Insulin Given to Resident - MN
The October 2025 inspection report describes a medication error that unfolded on the evening of October 16. The nurse, identified in records as RN-A, was preparing insulin for a resident when she was interrupted. She grabbed the wrong vial, fast-acting Novolog instead of the long-acting Lantus that had been ordered, and administered the full dose before catching the mistake.
The difference matters. Novolog acts quickly, dropping blood sugar within minutes of injection. Lantus works slowly over 24 hours. Giving 20 units of a rapid-acting insulin to a patient prescribed a basal insulin creates a real risk of hypoglycemia, the kind that can cause confusion, seizures, or loss of consciousness if blood sugar falls far enough and nobody catches it in time.
RN-A called the assistant administrator at 8:53 p.m. She called the director of nursing. There was, according to the assistant administrator, a significant amount of time without a call back from the on-call provider. So RN-A called 911.
She told the director of nursing she was scared. She stayed with the resident until the EMTs arrived.
The director of nursing later told inspectors she was unsure whether RN-A had rechecked the resident's blood sugar as instructed. The facility's own diabetes management protocols called for reporting hypoglycemia to a physician and contacting them if blood sugar fell below 80.
The following morning, the director of nursing spoke with RN-A by telephone. The conversation covered what went wrong and how to proceed. Improved communication between nurses. Limiting distractions. Moving the medication cart to a different location if interrupted. The rights of medication administration. These were the lessons identified.
RN-A was allowed to work that weekend.
A plan was put in place requiring a second nurse to check all of RN-A's insulin doses before administration going forward. The facility's root cause analysis pointed to distraction, lack of communication between the two nurses working that night, and failure to follow the electronic medication administration record.
The assistant administrator told inspectors the resident was not harmed and could possibly have been treated at the facility without calling 911.
Havenwood's own medication policy, dated December 2023, required nurses to verify the identity of a medication three times against the medication administration record: when taking the container from the cart, while preparing it, and again before returning it to the cart. For insulin specifically, a separate policy required confirming that the label matched the right resident, medication, dose, dosage form, frequency, and route.
The policy also stated that conversations and other distractions should be avoided while preparing medications.
None of that happened on the night of October 16.
Federal inspectors who reviewed the incident cited Havenwood under F0760, covering medication errors, and rated the level of harm as minimal or potential for actual harm. The facility serves a small number of residents affected by this finding.
What the record does not resolve is the stretch of time between when RN-A administered the wrong insulin and when a provider finally responded. The assistant administrator described it as a significant amount of time. The director of nursing was reached. The on-call provider was not. A nurse alone with a resident who had just received the wrong insulin, watching the clock, eventually decided the only person left to call was 911.
She was scared. She said so. And she was back at work two days later.
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: June 24, 2026 · Our methodology
Havenwood Care Center in BEMIDJI, MN was cited for violations during a health inspection on October 22, 2025.
The October 2025 inspection report describes a medication error that unfolded on the evening of October 16.
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.