Avantara Arrowhead
Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 26 Google reviews
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Quality Concerns Identified
Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.
- Special Focus Facility (under heightened CMS scrutiny)
- Abuse citation on record
- Low overall rating (1/5 stars)
- Low staffing rating (2/5 stars)
- Above-median deficiencies (28 vs median 5.0)
- High staff turnover (62%)
- High RN turnover (53%)
Bottom 25% in SD · Below recommended RN staffing · Worst in LEGACY HEALTHCARE chain · $40,014 in fines · Special Focus Facility (CMS) · Abuse citation
What this means for your family
The facility has shown a strong trend of positive feedback recently, particularly regarding their rehabilitation and communication. However, given the serious historical concerns regarding hygiene and clinical oversight, we recommend that families conduct a thorough tour and ask specifically about current protocols for incontinence care and medication administration.
Google Reviews
Google Reviews
26 reviews on Google“Avantara Arrowhead receives high praise for its rehabilitation services, with many families highlighting the attentive nursing staff and effective communication during the transition process. However, the facility has faced serious historical allegations regarding clinical care standards, including concerns about hygiene, medication management, and supervision of residents. Families should weigh the recent positive reports of professional care against these significant past complaints.”
Quality Themes
Tap a score for detailsStrengths
- Attentive and compassionate nursing staff
- Effective and responsive communication
- Strong rehabilitation therapy team
- Clean and well-maintained facility
Concerns
- Inadequate hygiene and incontinence care (mentioned by 2 reviewers)
- Missing personal belongings (mentioned by 2 reviewers)
- Poor clinical oversight and medication errors (mentioned by 2 reviewers)
Rating Trends
Tap a year to see what changed
Distribution · 29 analyzed
How They Respond to Reviews
This facility actively engages with reviewer feedback.
Questions for Your Tour
- 1I noticed the management team is very active in responding to feedback; how do you typically involve families in the process of addressing care concerns?
- 2What specific protocols do you have in place to ensure medication administration is accurate and double-checked by the nursing staff?
- 3How does the clinical team ensure that personal hygiene and incontinence care are handled consistently and with dignity for every resident?
- 4Can you walk me through the process for tracking and securing residents' personal belongings to prevent items from going missing?
- 5What is the procedure for handling a medical emergency during the night or over the weekend when the primary physician might not be on-site?
- 6What kind of daily activities or social outings do you have planned to keep the residents engaged and connected with one another?
Personalized based on this facility's data
Key Review Excerpts
“My mother stayed here after surgery and received exceptional care. The therapy team was top-tier, and the nurses were attentive and compassionate every step of the way.”
“My oldest brother is a resident there due to his lifelong developmental disability. He receives wonderful care from the staff and they treat him like family. They contact me quarterly to discuss his care and keep me updated on any issues.”
“The staff at Avantara Arrowhead have been above and beyond phenomenal with their care for my wife. From the first communication with the Director of Admissions who immediately whole heartedly welcomed my wife’s stay.”
Staffing
Staffing Hours
per resident/day · Medicare 2026Total nursing hours are below minimum, though RN coverage is adequate. This may mean fewer aides for daily tasks like bathing and mobility.
Quality Measures
Quality Measures
Resident outcomes compared with national, state, and local averages · 17 measures
3
measures
14
measures
Residents whose walking got worse
Residents on antipsychotic medication
Residents whose bladder or bowel control got worse
Residents needing more daily help over time
Residents on anti-anxiety or sleep medication
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Short-stay residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents newly given antipsychotics
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
This facility has concerning patterns with families filing 16 complaints that triggered federal inspections, revealing recurring issues with resident protection from abuse and neglect, accident prevention and safety, and pressure ulcer care. While most deficiencies show correction dates, problems persist across multiple surveys, including recent citations for medication management errors and infection control failures, suggesting ongoing quality concerns that warrant careful consideration.
Dec 10, 2025Complaint3
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Nov 6, 2025Complaint1
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Sep 11, 2025Routine15
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Resident Rights Deficiencies
Honor 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.
Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Quality of Life and Care Deficiencies
Provide care or services that was trauma informed and/or culturally competent.
Quality of Life and Care Deficiencies
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Sep 11, 2025Complaint1
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Jun 18, 2025Complaint3
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Mar 26, 2025Complaint2
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Federal Penalties
Fine
Sep 11, 2025
$65,700
Fine
Mar 5, 2025
$8,112
Fine
Jul 10, 2024
$8,018
Fine
Jul 10, 2024
$11,333
Fine
May 15, 2024
$12,695
Ownership & Operations
Who Operates This Facility
Avantara Arrowhead
for profit
Chain Affiliation
Legacy Healthcare
89 facilities nationwide
Chain avg rating: 3.0/5 · Rank 88 of 89 (Worst)
Ownership & Management
Owners
Doros Generation Trust U/a/d 1/3/12
Owner · Organization
Gpn Family Trust U/a/d 4/28/08
Owner · Organization
Oakway Operations LLC
Owner · Organization
Key personnel
Contact
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
26 reviews from families & visitors
Official Website
Visit avantaraarrowhead.com
Medicare data downloads
Original nursing home datasets
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Safer Alternatives Nearby
Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.
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