Havenwood Care Center
Havenwood Care Center in BEMIDJI, MN — inspection on October 22, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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 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. 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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/22/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Havenwood Care Center
1633 Delton Avenue NW Bemidji, MN 56601
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 10/22/25 at 11:46 a.m. director of nursing (DON) verified 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 R4 received the wrong dose (1/2 of what was ordered) from 9/21/25, through today 10/22/25. 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.
Facility ID: