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Nursing HomeMedicaid Investigative

Avantara Arrowhead

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

2500 Arrowhead Dr, Rapid City, SD 5770265 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
4.3/5

based on 26 Google reviews

5
4
3
2
1

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10/ 10
critical Risk

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

Source: Medicare data

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 details
Food8.0Staff7.0Clean6.0Activities7.0Meds2.0MemoryN/AComms8.0ValueN/A

Strengths

  • 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

2341.02020(3)5.02022(4)3.02023(3)4.02024(4)5.02025(14)5.02026(1)

Distribution · 29 analyzed

5
23
4
0
3
1
2
0
1
5

How They Respond to Reviews

92%response rate

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.

Rehab patient's family · 2025★★★★★

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.

Long-term resident's family · 2025★★★★★

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.

Long-term resident's family · 2025★★★★★
Source: 26 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.78hrs
OK
Registered nurses for medical care
Total Nursing
3.24hrs
79%
All nurses + aides combined
Staff Turnover
66%
Lower is better (< 30% = good)
RN Turnover
64%
Lower is better (< 30% = good)

Total 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

Medicare Rating
2/ 5
Better Than Avg

3

measures

Worse Than Avg

14

measures

Long-Stay Residents
🚶

Residents whose walking got worse

↓ Lower is better
This Facility32.8%
Worse than Avg
Here
32.8%
US
15.3%
SD
20.2%
Pennington
23.8%
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility32.3%
Worse than Avg
Here
32.3%
US
15.5%
SD
24.5%
Pennington
23.6%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility35.4%
Worse than Avg
Here
35.4%
US
19.4%
SD
25.6%
Pennington
26.5%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility24.9%
Worse than Avg
Here
24.9%
US
14.4%
SD
21.4%
Pennington
22.5%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility24.5%
Worse than Avg
Here
24.5%
US
19.5%
SD
17.5%
Pennington
14.6%
😔

Residents with depression symptoms

↓ Lower is better
This Facility13.3%
Worse than Avg
Here
13.3%
US
12.1%
SD
5.3%
Pennington
4.1%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility37.6%
Worse than Avg
Here
37.6%
US
81.8%
SD
82.7%
Pennington
70.6%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility48.5%
Worse than Avg
Here
48.5%
US
79.8%
SD
78.2%
Pennington
70.8%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility4.3%
Worse than Avg
Here
4.3%
US
1.6%
SD
1.9%
Pennington
1.1%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

23deficiencies
5penalties
Well above state avg (6.8)
16 complaint-triggered
$40,014 in fines

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, 2025Complaint
3
0684Potential for harm · IsolatedResolved (past non-compliance)

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0609Potential for harm · IsolatedResolved (past non-compliance)

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0697Potential for harm · IsolatedResolved (past non-compliance)

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Nov 6, 2025Complaint
1
0689Actual harm · IsolatedCorrected

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, 2025Routine
15
0686Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

0689Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0697Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

0695Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

0759Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0554Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

0578Potential for harm · IsolatedCorrected

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.

0583Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Keep residents' personal and medical records private and confidential.

0645Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

0657Potential for harm · IsolatedCorrected

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.

0699Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care or services that was trauma informed and/or culturally competent.

0745Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide medically-related social services to help each resident achieve the highest possible quality of life.

0842Potential for harm · IsolatedCorrected

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, 2025Complaint
1
0684Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Jun 18, 2025Complaint
3
0600Potential for harm · PatternCorrected

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.

0760Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

0580Potential for harm · IsolatedCorrected

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, 2025Complaint
2
0600Potential for harm · IsolatedResolved (past non-compliance)

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.

0684Potential for harm · IsolatedCorrected

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

Owner / Operator

Avantara Arrowhead

Organization Type

for profit

Chain Affiliation

Chain Name

Legacy Healthcare

Chain Size

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

43%

Gpn Family Trust U/a/d 4/28/08

Owner · Organization

43%

Oakway Operations LLC

Owner · Organization

15%

Key personnel

Arrowhead Sd Property Holdings, LLC5% or Greater Security InterestTruist Bank5% or Greater Security InterestRajchenbach, ChaimManaging Control - Governing BodyShabat, MenachemManaging Control - Governing BodyLegacy Healthcare Financial Services LLCManager
Source: Medicare provider data

Contact

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References & Resources

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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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