Havenwood Care Center: Insulin Dosing Error Triggers 911 - MN
The incident happened on the evening of October 16, 2025. RN-A was preparing insulin for a resident identified in the report only as R1 when she was interrupted. She grabbed the wrong vial, short-acting insulin instead of long-acting, and administered it before she realized the mistake.
She called the facility's director of nursing and the resident's provider. Neither called back quickly. She called 911.
The assistant administrator told inspectors on October 22 that R1 was not harmed and could possibly have been treated at the facility without the emergency call. She said the investigation traced the error to distraction.
The facility's own medication policy, dated December 2023, required nurses to verify the identity of a medication three times against the administration record: when removing it from the cart, while preparing it, and before putting it back. A separate insulin policy required confirming the right resident, medication, dose, dosage form, frequency, and route. The policy on medication preparation stated that conversations and other distractions should be avoided entirely.
None of that stopped what happened on October 16.
After the incident, the facility allowed RN-A to work the following weekend. A second nurse was assigned to check her insulin doses before administration. She was told that if she felt distracted while preparing medications, she should move the cart to a different location.
Inspectors classified the violation as causing minimal harm or potential for actual harm, and noted few residents were affected.
R1's blood sugar was not recorded before the wrong insulin was given. Whether anyone checked it in the hours after, the 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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
HAVENWOOD CARE CENTER in BEMIDJI, MN was cited for violations during a health inspection on October 22, 2025.
The incident happened on the evening of October 16, 2025.
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.