Havenwood Care Center, Bemidji, MN

The Essentials

Summary

Across 12 inspections from October 2023 to April 2026, state surveyors documented 48 findings at Havenwood Care Center; 48 have a recorded correction; CMS lists 4 enforcement actions in the window.

Inspections: 12; 2023–2026, standard and complaint
Findings: 48; Deficiencies cited by state inspectors
Corrected: 48; Of 48 findings, with a recorded correction date
Penalties: 4; 3 fines; payment not published, 1 closed

Findings by Year

Findings
Of which, actual harm (level G or above)

* Partial year, through October 1, 2026.

Findings by year
Year	Inspections	Findings	Of which, actual harm (level G or above)
2023	2	2	2
2024	3	15	0
2025	5	20	1
2026	2	11	1

What the Record Shows

48 of 48 findings have a recorded correction date.
CMS lists 4 enforcement actions in the window: 3 fines totaling $129,052, their payment not published; denial of payment imposed January 16, 2026, ended March 19, 2026.
11 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
The latest standard inspection, April 29, 2026, recorded 10 findings (most serious: Level E).

What to Ask About

Accident Hazards and Supervision, Cited in Four Inspections
Reporting Suspected Abuse, Cited in Two Inspections
Care Plan Timing and Review, Cited in Two Inspections
Pressure Injury Care, Cited in Two Inspections
Pharmacy Services, Cited in Two Inspections
Significant Medication Errors, Cited in Two Inspections
Medication Labeling and Storage, Cited in Two Inspections
Infection Control, Cited in Two Inspections

Report at a Glance

Facility: Havenwood Care Center
Address: 1633 Delton Avenue NW, Bemidji, MN 56601
CMS Certification Number: 245397
Provider Type: Skilled nursing facility and nursing facility
Certified Beds: 65
Ownership: For profit - Corporation
Record Window: October 6, 2023 to October 1, 2026

Chronology

Inspection History

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

Apr 292026
Standard health inspection
10 findings
The same visit included a complaint investigation.
- F688Provide 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.Level ENo actual harm, potential for moreCorrected Jun 12, 2026
- F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected Jun 12, 2026
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Jun 12, 2026
- F585Honor 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.Level DNo actual harm, potential for moreCorrected Jun 12, 2026
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Jun 12, 2026
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Jun 12, 2026
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Jun 12, 2026
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Jun 12, 2026
- F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Level DNo actual harm, potential for moreCorrected Jun 12, 2026
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jun 12, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Jan 162026
Complaint investigation
1 finding
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Mar 19, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Oct 222025
Complaint investigation
2 findings
- F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Dec 22, 2025
- F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level DNo actual harm, potential for moreCorrected Dec 22, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Aug 72025
Complaint investigation
1 finding
- F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Level JImmediate jeopardyCorrected Aug 31, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Jul 172025
Complaint investigation
1 finding
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Aug 15, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Jun 112025
Complaint investigation
1 finding
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Jul 14, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Feb 122025
Standard health inspection
15 findings
- F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level ENo actual harm, potential for moreCorrected Mar 31, 2025
- F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level DNo actual harm, potential for moreCorrected Mar 31, 2025
- F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Mar 31, 2025
- F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel DNo actual harm, potential for moreCorrected Mar 31, 2025
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Mar 31, 2025
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Mar 31, 2025
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Mar 31, 2025
- F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Mar 31, 2025
- F711Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.Level DNo actual harm, potential for moreCorrected Mar 31, 2025
- F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.Level DNo actual harm, potential for moreCorrected Mar 31, 2025
- F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Level DNo actual harm, potential for moreCorrected Mar 31, 2025
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Mar 31, 2025
- F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Mar 31, 2025
- F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Level DNo actual harm, potential for moreCorrected Mar 31, 2025
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Mar 31, 2025
Enforcement Action
Civil money penalty, $26,685 imposed June 11, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 12, 2025, the nearest before the penalty date.
Enforcement Action
Civil money penalty, $88,970 imposed January 16, 2026. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 12, 2025, the nearest before the penalty date.
Enforcement Action
Denial of payment imposed January 16, 2026. Status: Closed, March 19, 2026. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 12, 2025, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Jun 42024
Complaint investigation
2 findings
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Jul 1, 2024
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jul 1, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
May 92024
Complaint investigation
1 finding
- F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Level DNo actual harm, potential for moreCorrected Jun 15, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Apr 52024
Standard health inspection
12 findings
The same visit included a complaint investigation.
- F809Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.Level FNo actual harm, potential for moreCorrected May 10, 2024
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level ENo actual harm, potential for moreCorrected May 10, 2024
- F610Respond appropriately to all alleged violations.Level ENo actual harm, potential for moreCorrected May 10, 2024
- F729Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.Level ENo actual harm, potential for moreCorrected May 10, 2024
- F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected May 10, 2024
- F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Level DNo actual harm, potential for moreCorrected May 10, 2024
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level DNo actual harm, potential for moreCorrected May 10, 2024
- F625Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.Level DNo actual harm, potential for moreCorrected May 10, 2024
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected May 10, 2024
- F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected May 10, 2024
- F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected May 10, 2024
- F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level DNo actual harm, potential for moreCorrected May 10, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Dec 42023
Complaint investigation
1 finding
- F760Ensure that residents are free from significant medication errors.Level JImmediate jeopardyCorrected Dec 28, 2023
Enforcement Action
Civil money penalty, $13,397 imposed December 4, 2023. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the complaint investigation of December 4, 2023, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Oct 62023
Complaint investigation
1 finding
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Sep 28, 2023
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

Context

Patterns Worth Examining

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1
Accident Hazards and Supervision, Cited in Four Inspections
Inspectors cited F689 in October 2023, February 2025, June 2025 and January 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232324242425252525252626F689 across all 12 inspections, oldest to newest
2
Reporting Suspected Abuse, Cited in Two Inspections
Inspectors cited F609 in April 2024 and July 2025. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232324242425252525252626F609 across all 12 inspections, oldest to newest
3
Care Plan Timing and Review, Cited in Two Inspections
Inspectors cited F657 in February 2025 and April 2026. This citation covers whether care plans are written on time and revised by a team that includes the resident’s caregivers. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232324242425252525252626F657 across all 12 inspections, oldest to newest
4
Pressure Injury Care, Cited in Two Inspections
Inspectors cited F686 in April 2024 and April 2026. This citation covers how the home prevents and treats pressure injuries (bedsores). None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232324242425252525252626F686 across all 12 inspections, oldest to newest
5
Pharmacy Services, Cited in Two Inspections
Inspectors cited F755 in February 2025 and April 2026. This citation covers pharmacy services and the licensed pharmacist who oversees them. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232324242425252525252626F755 across all 12 inspections, oldest to newest
6
Significant Medication Errors, Cited in Two Inspections
Inspectors cited F760 in December 2023 and October 2025. This citation covers whether residents are free from significant medication errors. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232324242425252525252626F760 across all 12 inspections, oldest to newest
7
Medication Labeling and Storage, Cited in Two Inspections
Inspectors cited F761 in April 2024 and October 2025. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232324242425252525252626F761 across all 12 inspections, oldest to newest
8
Infection Control, Cited in Two Inspections
Inspectors cited F880 in February 2025 and April 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232324242425252525252626F880 across all 12 inspections, oldest to newest

For Your Next Visit

Questions to Ask on Your Visit

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

01
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in four inspections, most seriously at level J.
02
How are staff trained to report suspected abuse or neglect, and who reports it to the state?
Reporting Suspected Abuse: cited in two inspections, most seriously at level E.
03
How often are care plans revised, and who takes part in the review?
Care Plan Timing and Review: cited in two inspections, most seriously at level D.
04
How often are residents checked for pressure injuries and repositioned, and who is responsible for it?
Pressure Injury Care: cited in two inspections, most seriously at level D.
05
How often does the consultant pharmacist review each resident’s medications?
Pharmacy Services: cited in two inspections, most seriously at level D.
06
What happened after the medication error citation, and how are high-risk drugs double-checked?
Significant Medication Errors: cited in two inspections, most seriously at level J.
07
How are medications stored and secured, and who checks the medication carts?
Medication Labeling and Storage: cited in two inspections, most seriously at level D.
08
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in two inspections, most seriously at level D.
09
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
Insufficient nursing staff was cited in April 2026.
10
What led to the 2026 fine, and has it been paid?
An $88,970 civil money penalty was imposed January 16, 2026. CMS publishes the fine, not whether it has been paid. The record holds four enforcement actions in the window.

The Evidence

Sources and Coverage

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Minnesota state survey agency.

Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Minnesota state survey agency
Inspection Oct 6, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Minnesota state survey agency
Inspection Dec 4, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Minnesota state survey agency
Inspection Apr 5, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Minnesota state survey agency
Inspection May 9, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Minnesota state survey agency
Inspection Jun 4, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Minnesota state survey agency
Inspection Feb 12, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Minnesota state survey agency
Inspection Jun 11, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Minnesota state survey agency
Inspection Jul 17, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Minnesota state survey agency
Inspection Aug 7, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Minnesota state survey agency
Inspection Oct 22, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Minnesota state survey agency
Inspection Jan 16, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Minnesota state survey agency
Inspection Apr 29, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Penalties, Provider Data Catalog
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
View Dataset ↗
Provider Information, Provider Data Catalog
Centers for Medicare & Medicaid Services · 245397
Published Oct 1, 2026 · Retrieved Nov 1, 2026
View Dataset ↗

Coverage

Record windowOctober 6, 2023 – October 1, 2026

CMS publishes about three inspection cycles; inspections before October 2023 are not in this release.
CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.

What This Report Cannot Tell You

Complaints not investigated onsite: Allegations screened out by the state before an onsite visit are not published.
Complaint allegations: CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
Facility-reported incidents: Self-reported incidents appear only if they led to an inspection.
Follow-up visits: CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
Fire safety inspections: Published by CMS separately and not included in this record yet.
Staffing levels and ownership history: Published by CMS separately and not included in this record.
Whether fines were paid: CMS publishes the fines imposed, not whether or when they were paid.

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.