Cycle 1
Health 2025-07-09 · Fire 2025-07-09
4 health deficiencies
Top issue: Infection Control (1 deficiency)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Bagley, MN
Cornerstone Nsg & Rehab Center
3-star overall rating with 3-star inspections with $12,649 in total fines with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
416 Seventh Street Northeast, Bagley, MN
(218) 694-6552
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
47
Certified beds
Average residents
41
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1986-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.97
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.54
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
3.29
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.80
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.50
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.88
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.44
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.08
CMS adjusted RN staffing hours
Adjusted total hours
5.37
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
18%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,841
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
47.43
Composite VBP score used to determine payment impact.
Payment multiplier
1.0010
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
3.8
Baseline 27.66% · Performance 48.15% · Measure score 3.8 · Achievement 3.8 · Improvement 0
Adjusted total nurse staffing
5.69
Baseline 4.73 hours · Performance 4.70 hours · Measure score 5.69 · Achievement 5.69 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.53% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 33 · Observed rate 9.09% · Lower 95% interval 7.5% |
| Discharge to community | 55.4% |
50.57%
4.8 pts better
|
No Different than the National Rate · Eligible stays 28 · Observed rate 50% · Lower 95% interval 38.84% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 18 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 12 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 2.41% |
8.2%
5.8 pts worse
|
Numerator 2 · Denominator 83 |
| Staff flu vaccination coverage | 12.82% |
42%
29.2 pts worse
|
Numerator 10 · Denominator 78 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.0% |
97.3%
0.7 pts better
|
93.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.4% · Q3 97.4% · Q4 97.3% · 4Q avg 98.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.5% |
96.1%
1.4 pts better
|
95.5%
2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.0% |
3.9%
4.1 pts worse
|
3.3%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 10.5% · Q3 7.9% · Q4 8.1% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.5% |
4.3%
1.8 pts better
|
11.4%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.3% · Q3 3.1% · Q4 3.0% · 4Q avg 2.5% |
| Percentage of long-stay residents who lose too much weight | 7.1% |
4.1%
3 pts worse
|
5.4%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 8.3% · Q3 2.9% · Q4 8.3% · 4Q avg 7.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 38.9% |
12.4%
26.5 pts worse
|
19.6%
19.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.9% · Q2 36.8% · Q3 35.1% · Q4 37.8% · 4Q avg 38.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.6% |
17.5%
3.9 pts better
|
16.7%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 6.9% · Q3 16.1% · Q4 16.7% · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.6% |
22.5%
4.9 pts better
|
16.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.6% |
18.6%
11 pts worse
|
14.9%
14.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.4% · Q2 22.6% · Q3 33.3% · Q4 28.1% · 4Q avg 29.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
2.3%
0.6 pts better
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.2% · Q3 3.1% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.8% |
2.6%
0.2 pts worse
|
1.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 2.8% · Q4 5.6% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.0% |
24.8%
4.2 pts worse
|
19.8%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.1% · Q2 28.4% · Q3 16.5% · Q4 44.9% · 4Q avg 29.0% |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
5.4%
0.6 pts worse
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 8.0% · Q3 7.1% · Q4 5.8% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.6% |
88.6%
4 pts better
|
81.7%
10.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.4% · Q2 87.9% · Q3 88.9% · Q4 97.4% · 4Q avg 92.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 27.1% |
14.0%
13.1 pts worse
|
12.0%
15.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.1% · Observed 26.1% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.4% |
1.9%
3.5 pts worse
|
1.6%
3.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 5.0% · Q3 3.7% · Q4 7.4% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.2% |
82.7%
8.5 pts better
|
79.7%
11.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.1% |
23.1%
About the same
|
23.9%
0.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.1% · Observed 21.7% · Expected 22.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-17 · Fire 2024-07-17
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-09-20 · Fire 2023-09-20
12 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-08-01
F · Potential for more than minimal harm
2025-07-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-08-11
E · Potential for more than minimal harm
2025-07-09
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-08-11
D · Potential for more than minimal harm
2025-07-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-07-09
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-08-11
D · Potential for more than minimal harm
2025-07-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-08-11
F · Potential for more than minimal harm
2024-07-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-23
F · Potential for more than minimal harm
2024-07-17
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-09-05
D · Potential for more than minimal harm
2024-07-17
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-08-23
F · Potential for more than minimal harm
2023-09-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-26
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-12-17
E · Potential for more than minimal harm
2025-07-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-08-18
D · Potential for more than minimal harm
2025-07-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-08-18
D · Potential for more than minimal harm
2025-07-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-25
E · Potential for more than minimal harm
2024-07-17
F761 · Pharmacy Service Deficiencies
Health
Ensure 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.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-17
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-17
F758 · Pharmacy Service Deficiencies
Health
Implement 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.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-17
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-04-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-13
E · Potential for more than minimal harm
2023-09-20
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-09-20
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-09-20
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-09-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-09-20
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-09-20
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-09-20
F758 · Pharmacy Service Deficiencies
Health
Implement 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.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-09-20
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-07-11
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-11
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-08-11
J · Immediate jeopardy
2023-04-19
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2023-04-06
D · Potential for more than minimal harm
2023-04-19
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-05-09
Penalties and ownership
What sits behind the stars
$12,649
2023-04-19
Fine
Fine · fine $12,649
Fine
Ownership
Potvin Holdings Incorporated
5% Or Greater Direct Ownership Interest · Organization
Potvin, Allen
5% Or Greater Indirect Ownership Interest · Individual
Potvin, Judith
5% Or Greater Indirect Ownership Interest · Individual
Health Services Network Inc
Operational/Managerial Control · Organization
Potvin, Allen
Corporate Director · Individual
Potvin, Allen
Corporate Officer · Individual
Potvin, Allen
W-2 Managing Employee · Individual
Potvin, Judith
Corporate Director · Individual
Potvin, Judith
Corporate Officer · Individual
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