Havenwood Care Center

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

8:30 p.m. and 9:00 p.m. regarding a significant medication error. Resident R1 had received 20 units of the wrong type of insulin, Novolog instead of Lantus as ordered. RN-A was instructed to call the on-call provider, monitor blood sugars, watch for symptoms of hypoglycemia (low blood sugars), and stay with Resident R1 until EMTs arrived. RN-A stated to DON, she was scared so called EMT for assistance, and stayed with Resident R1. DON was unsure if RN-A rechecked the BS as instructed. The root cause analysis identified the cause of the medication error was lack of communication between the two nurses working that evening, distraction, lack of the rights of medication administration and EMAR/orders were not followed. The following morning, DON discussed the medication error with RN-A on the telephone and how to proceed going forward. The rights of medication administration would be expected to be followed, vital signs and blood sugars should have been monitored, improved communication among nurses, and to limit distractions. RN-A was allowed to work the weekend, and a plan was created to have a second nurse check all RN-A's insulin doses prior to administration. RN-A was also instructed, when distracted during medication preparation move the cart and relocate to a different location to help prevent medication errors, required further re-education now, ongoing, and disciplinary action. During an interview on 10/22/25 at 12:37 p.m., assistant administrator stated she was contacted on 10/16/25 at 8:53 p.m., by RN-A regarding a medication error. RN-A informed her she was about to prepare Resident R1's insulin, was interrupted, grabbed the wrong insulin (short acting versus long acting), had not realized it until after it was administered. DON and provider were contacted with a significant amount of time without a call back. RN-A called 911. Assistant administrator stated our investigation identified the root cause of the medication error was distraction. Resident R1 was not harmed and could have possible been treated here at the facility. Facility Standards of Care and Protocols for Diabetes Management dated 3/2013, identified report hypoglycemia incident to physician. Call if less than 80. Facility policy Administering Medications dated 12/2023, identified all RN's, LPNs, and TMAs employed at the facility will be trained to do the medication passes according to industry standards. Conversations or other distractions should be avoided while preparing medications. The labels of all medicine bottles and cards will be neat and legible. The nurse may never re-label a medication. It must be sent to pharmacy or a new label brought in by the pharmacist and applied by them. Injectable medications will be administered according to facility policy for safe injection practices and by only a licensed nursing staff. TMAs cannot administer injectable medications. High risk medications: a list of high-risk medications will be available at each nurse's station and on each medication cart. The identity of medication will be verified three times with the MAR, when taking the container from the cart, as preparing it, and before replacing it in the cart. Facility policy Insulin Administration - Pen identified verification of the insulin medication/prescription (RX) label matches

the medication administration record (MAR): right resident, medication, dose, dosage form, frequency and route.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Havenwood Care Center

1633 Delton Avenue NW Bemidji, MN 56601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

change refer to EMAR. She verified there was not an orange sticker on the bottle. She had been off work for 6 weeks and just returned yesterday. TMA-A verified located in the Baclofen pill bottle label 2 on top (10 mg tablets) were 73 whole pills and 5 half pills. She stated there had to be other staff that had made medication errors on this same medication, yesterday she had placed 3 half pills back into the medication bottle and now there were five. The pills were 10 mg each and there would be no reason to cut them in half. At 11:07 a.m. TMA-A placed an orange-colored label direction sticker printed, DIRECTIONS CHANGED REFER TO CHART, over the written directions on the pill bottle and back into the located medication cart. She notified

the staff nurse and requested the half pills be destroyed, reported to the DON, a mediation error filed, to avoid further errors. During an interview on 10/22/25 at 11:46 a.m. director of nursing (DON) verified Resident R4's Baclofen dose was increased on 8/28/25 to 30 mg twice a day 7:00 a.m. and 9:00 p.m. and the other dose remained the same 20 mg twice a day at 12:00 p.m. and 5:00 p.m. On 9/6/25, the pharmacy sent over enough pills for two weeks in a bubble pack each one had 1 1/2 tabs. They ran out of that dose on 9/20/25, and staff started to use the 10 mg tablet bottle (her own she brought in from home), there were times when staff used home medications brought in. The order should have been reactivated to take 30 mg at 7:00 a.m. and 9:00 p.m. and was not done. The order was correct, but label and order did not match; label 20 mg 1 1/2 tablets twice a day and the label on the Baclofen bottle indicated 10 mg tablets. The staff had not completed the rights of medication administration and unfortunately Resident R4 received the wrong dose (1/2 of what was ordered) from 9/21/25, through today 10/22/25. Resident R4 was prescribed the Baclofen for spasms and had not seen any increased pain that she was aware of. TMA-A reported medication errors this morning and explained as to what happened. Facility policy General Policies in Administrating Medications dated 12/2023, identified the labels of all medicine bottles and cards will be neat and legible. The nurse may never re-label a medication. It must be sent to pharmacy if re-labeling is necessary or a new label brought in by

the pharmacist and applied by them. Labels shall include prescription number, name of drug, strength, quantity of drug, expirations date, directions for use, name of resident, physician's name, date of refill and if

a generic the name of medication being given for. Errors of omission, dosage or type of medication must be reported at once to the registered nurse (RN) supervisor and an incident report filled out. Requested facility policy medication cart safety and was not received.

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