Havenwood Care Center
HAVENWOOD CARE CENTER in BEMIDJI, MN — inspection on April 29, 2026.
Found 10 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
Federal health inspectors cited Havenwood Care Center in BEMIDJI, MN for a deficiency under regulatory tag F-F0585 during a standard health inspection conducted on 2026-04-29.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 10 deficiencies cited during this inspection of Havenwood Care Center.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-06-12.
Federal health inspectors cited Havenwood Care Center in BEMIDJI, MN for a deficiency under regulatory tag F-F0657 during a standard health inspection conducted on 2026-04-29.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 10 deficiencies cited during this inspection of Havenwood Care Center.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-06-12.
During observation on 4/28/26, at 10:38 a.m. R18 was seated in his wheelchair in the Walnut Grove
remained unshaven.
During observation on 4/29/26, at 8:59 a.m. R18 was seated in his wheelchair in the hallway. R18's was clean shaven.
When interviewed on 4/29/26, at 9:00 a.m. LPN-B stated she was not sure why the aides would not have shaved R18 on 4/27/26, or 4/28/26, but he was shaved today.
There were different nursing assistants on then there were the other two days. R18 was supposed to be shaved every day.
When interviewed on 4/29/26, at 9:53 a.m. RN-B stated R18 should be shaven daily. RN-B was not sure why R18 was not shaved the other two days. RN-B was aware R18's shaver battery was very low when he was shaved that morning, so perhaps that was the reason, but the goal was to shave him every day. R18 could have refused, however the point of care documentation did not indicate R18 refused care.
During interview on 4/29/26, at 9:54 a.m. NA-B stated she was not sure why R18 was not shaved the previous two days, but he was shaven now. R18 was supposed to be shaven every day.
Some of the younger NA's just did not notice or didn't know better. R18 never refused assistance with cares and always allowed them to assist hiem to shave daily without any problems.
During interview on 4/29/26, at 4:36 p.m. the DON stated she would have expected staff to shave R18 as care planned or document why it could not be completed.
The facility Quality of Care Policy reviewed 10/2023, identified based on the comprehensive assessment of a resident the facility strove to ensure residents received treatment and care in accordance with professional standards of practice, their comprehensive care plan and their personal preferences.
The facility provides the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with State and Federal Regulations.
245397 04/29/2026
Havenwood Care Center 1633 Delton Avenue NW Bemidji, MN 56601
Federal health inspectors cited Havenwood Care Center in BEMIDJI, MN for a deficiency under regulatory tag F-F0686 during a standard health inspection conducted on 2026-04-29.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 10 deficiencies cited during this inspection of Havenwood Care Center.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-06-12.
Federal health inspectors cited Havenwood Care Center in BEMIDJI, MN for a deficiency under regulatory tag F-F0688 during a standard health inspection conducted on 2026-04-29.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 10 deficiencies cited during this inspection of Havenwood Care Center.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-06-12.
During an interview on 4/29/26 at 4:04 p.m. the director of nursing (DON) stated there are two aides who worked the restorative nursing program and they are both part time.
For about 6 months the facility only had one part-time restorative aide.
The restorative aides would start with the FMPs right away when they get to the facility, but they are frequently called out to floor to work as a NA.
This is because of call-ins or short staffing on the floor.
She stated it was not acceptable to be pulling the restorative aides to the floor all the time, because they have close to fifty residents to assist and are unable to get to all of them in a week and the residents go without their FMP.A staffing policy was not obtained.
245397 04/29/2026
Havenwood Care Center 1633 Delton Avenue NW Bemidji, MN 56601
Federal health inspectors cited Havenwood Care Center in BEMIDJI, MN for a deficiency under regulatory tag F-F0755 during a standard health inspection conducted on 2026-04-29.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 10 deficiencies cited during this inspection of Havenwood Care Center.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-06-12.
Federal health inspectors cited Havenwood Care Center in BEMIDJI, MN for a deficiency under regulatory tag F-F0805 during a standard health inspection conducted on 2026-04-29.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 10 deficiencies cited during this inspection of Havenwood Care Center.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-06-12.
Federal health inspectors cited Havenwood Care Center in BEMIDJI, MN for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2026-04-29.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 10 deficiencies cited during this inspection of Havenwood Care Center.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-06-12.
During interview, NA-C stated when he emptied a resident's catheter, he always wore gloves and if there was a risk of infection then he would also wear a gown. NA-C stated he had worn gloves but not a gown when he emptied R25's catheter. NA-C stated there was a risk of splashing urine onto his clothes and potentially spreading bacteria to another resident. NA-C stated he should have worn a gown with R25's catheter cares.R66R66's quarterly Minimum Data Set (MDS) dated [DATE], identified R66 required extensive assistance from staff for all activities of daily living (ADL's) and diagnoses included colostomy, diabetes, and Alzheimer's disease.R66's care plan dated 8/27/21, identified R66 was at risk for alteration in nutrition due to gastric tube, tube feedings and not taking nutrition by mouth.
The care plan did not address what PPE staff should where with cares. On 4/29/26 at 10:00 a.m., registered nurse (RN)-C was at R66's bedside and administering medication through the resident's gastrostomy tube (G-tube).
Nursing assistant (NA)-D entered the room, put on a pair of gloves and walked to the resident's bedside. RN-C and NA-D were on either side of the bed. RN-C was wearing a gown and gloves. NA-D was wearing gloves, however, was not wearing a gown. R66's bed was thigh-height, and the resident was lying in bed with a lift sheet behind her hips and back, and her legs were resting on pillows behind her calves. RN-C and NA-D leaned over the bed and used the lift sheet to scoot the resident up towards the top of the bed. RN-C and NA-D walked to the foot of the bed and lifted and repositioned the pillows behind R66's lower legs. NA-D walked into the bathroom, removed her gloves, washed her hands and then exited the room. RN-C stated R66 was at risk for infection because of her g-tube and NA-D should have worn a gown and gloves while assisting with direct care.During interview on 4/29/26 at 10:35 a.m., NA-D stated she usually wears a gown when caring for residents with any type of tubes including g-tubes, although forgot to put on a gown when she repositioned R66.
NA-D stated wearing a gown was important to prevent bringing in and spreading bacteria to R66, as well as to help prevent spreading bacteria to/from other residents.During interview on 4/29/26 at 5:26 p.m., director of nursing (DON) stated staff should wear a gown and gloves when providing direct cares for a resident with indwelling tubes including catheters and tube feedings.
Direct care included anytime staff touched the residents and included emptying a catheter and repositioning residents in bed.The facility Enhanced Barrier Precautions policy dated 3/26, identified EBP expanded the use of PPE and referred to the use of gown and gloves during high-contact resident care activities that provided opportunities for transfer of multidrug-resistant organism (MDRO)'s to staff hands and clothing. MDRO's may indirectly be transferred from resident to resident during high contact care activities.
Resident with wounds and indwelling medical devices are at an especially high risk of both acquisition of and colonization with MDRO's.
The policy further identified EBP would be implemented for residents with wounds and/or indwelling medical devices during high-contact resident care activities regardless of MDRO infection or colonization.
High risk care activities included device care or use.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.