Avantara Arrowhead
2500 Arrowhead Dr · Rapid City, SD · 57702 · 6053480285
68 certified beds For profit - Limited Liability company Chain: Legacy Healthcare
Why this verdict
- Carries CMS’s abuse warning icon.
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $93,163 in fines in the last 24 months.
- Inspection results are getting worse cycle over cycle, not better.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
5 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
$93,163 in federal fines in the last 24 months
4 fines — CMS fines are reserved for verified, serious non-compliance.
66% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 2 of 5 Quality measures: 2 of 5
| Total nurse hours / resident-day | 3.24 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.78 | 0.55–0.75 |
| Weekend hours / resident-day | 2.90 | ≈ weekday level |
| Nursing turnover / year | 66% | median 45% |
| Fines (3-yr window) | 5 · $105,858 |
Inspection citations (37 in the current record)
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Potential for harm · D December 10, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Past Non-Compliance · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 10, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Past Non-Compliance · Quality of Life and Care
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Potential for harm · D December 10, 2025 · found via complaint
Provide safe, appropriate pain management for a resident who requires such services.
Past Non-Compliance · Quality of Life and Care
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Actual harm · G November 6, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected December 6, 2025 · Quality of Life and Care
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Actual harm · G September 11, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected October 15, 2025 · Quality of Life and Care
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Actual harm · G September 11, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected October 15, 2025 · Quality of Life and Care
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Actual harm · G September 11, 2025
Provide safe, appropriate pain management for a resident who requires such services.
Corrected October 15, 2025 · Quality of Life and Care
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Actual harm · G September 11, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected October 15, 2025 · Quality of Life and Care
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Potential for harm · D September 11, 2025
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected October 15, 2025 · Resident Rights
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Potential for harm · D September 11, 2025
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.
Corrected October 15, 2025 · Resident Rights
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Potential for harm · D September 11, 2025
Keep residents' personal and medical records private and confidential.
Corrected October 15, 2025 · Resident Rights
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Potential for harm · D September 11, 2025
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected October 15, 2025 · Resident Assessment and Care Planning
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Potential for harm · D September 11, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected October 15, 2025 · Resident Assessment and Care Planning
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Potential for harm · E September 11, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Corrected October 15, 2025 · Quality of Life and Care
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Potential for harm · D September 11, 2025
Provide care or services that was trauma informed and/or culturally competent.
Corrected October 15, 2025 · Quality of Life and Care
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Potential for harm · D September 11, 2025
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected October 15, 2025 · Quality of Life and Care
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Potential for harm · E September 11, 2025
Ensure medication error rates are not 5 percent or greater.
Corrected October 15, 2025 · Pharmacy Service
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Potential for harm · E September 11, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected October 15, 2025 · Nutrition and Dietary
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Potential for harm · D September 11, 2025
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected October 15, 2025 · Resident Assessment and Care Planning
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Potential for harm · E September 11, 2025
Provide and implement an infection prevention and control program.
Corrected October 15, 2025 · Infection Control
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Potential for harm · D June 18, 2025 · found via complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected July 18, 2025 · Resident Rights
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Potential for harm · E June 18, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected July 18, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E June 18, 2025 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected July 18, 2025 · Pharmacy Service
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Potential for harm · D March 26, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected March 25, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D March 26, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected April 30, 2025 · Quality of Life and Care
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| September 11, 2025 | Fine | $65,700 |
| March 5, 2025 | Fine | $8,112 |
| July 10, 2024 | Fine | $8,018 |
| July 10, 2024 | Fine | $11,333 |
| May 15, 2024 | Fine | $12,695 |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 435051 · certified since January 1, 1991. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.