Nursing Care Index

Avantara Arrowhead

Rapid City, Pennington County, South Dakota · CCN 435051 · For-profit (LLC) · part of Legacy Healthcare (89 facilities, chain average 2.9 stars)

CMS rates Avantara Arrowhead 1 of 5 overall as of August 2026. 68 certified beds, 59 residents a day on average. 45 citations on record from the current inspection cycles, 10 involving actual harm; 6 fines totalling $153,583.

On record

CMS’s ratings

The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.

Overall★☆☆☆☆ 1 of 5
Health inspections★☆☆☆☆ 1 of 5
Staffing★★☆☆☆ 2 of 5
Quality measures★★☆☆☆ 2 of 5
Quality: long-stay / short-stay1 / 2 of 5

Staffing

Total nurse staffing3.52278 hours per resident per day
Registered nurses0.98352 hours per resident per day
Weekend total3.26944 hours per resident per day
Nursing staff turnover76.1% (registered nurses 75%)
Administrators who left0

Citations from health inspections

Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.

SurveyFindingSeverityStatus
2026-06-22
complaint survey
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
G Actual harm that is not immediate jeopardy; isolated Past Non-Compliance
2026-03-27
2026-06-22
complaint survey
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Administration Deficiencies · tag F0867
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has plan of correction
2026-08-04
2026-06-22 Allow residents to self-administer drugs if determined clinically appropriate.
Resident Rights Deficiencies · tag F0554
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has plan of correction
2026-08-04
2026-06-22
complaint survey
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600
E No actual harm, with potential for more than minimal harm; pattern Past Non-Compliance
2026-04-19
2026-06-22
complaint survey
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · tag F0658
E No actual harm, with potential for more than minimal harm; pattern Past Non-Compliance
2026-06-15
2026-06-22 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has plan of correction
2026-08-04
2026-06-22
complaint survey
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · tag F0550
D No actual harm, with potential for more than minimal harm; isolated Past Non-Compliance
2026-06-12
2026-06-22 Provide 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.
Quality of Life and Care Deficiencies · tag F0688
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has plan of correction
2026-08-04
2026-06-22 Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · tag F0695
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has plan of correction
2026-08-04
2025-12-10
complaint survey
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609
D No actual harm, with potential for more than minimal harm; isolated Past Non-Compliance
2025-12-10
complaint survey
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
D No actual harm, with potential for more than minimal harm; isolated Past Non-Compliance
2025-12-10
complaint survey
Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care Deficiencies · tag F0697
D No actual harm, with potential for more than minimal harm; isolated Past Non-Compliance
2025-11-06
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2025-12-06
2025-09-11
complaint survey
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2025-10-15
2025-09-11 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2025-10-15
2025-09-11 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2025-10-15
2025-09-11 Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care Deficiencies · tag F0697
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2025-10-15
2025-09-11 Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · tag F0695
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-10-15
2025-09-11 Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · tag F0759
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-10-15
2025-09-11 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-10-15
2025-09-11 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-10-15
2025-09-11 Allow residents to self-administer drugs if determined clinically appropriate.
Resident Rights Deficiencies · tag F0554
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-10-15
2025-09-11 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 · tag F0578
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-10-15
2025-09-11 Keep residents' personal and medical records private and confidential.
Resident Rights Deficiencies · tag F0583
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-10-15
2025-09-11 PASARR screening for Mental disorders or Intellectual Disabilities
Resident Assessment and Care Planning Deficiencies · tag F0645
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-10-15
2025-09-11 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies · tag F0657
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-10-15
2025-09-11 Provide care or services that was trauma informed and/or culturally competent.
Quality of Life and Care Deficiencies · tag F0699
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-10-15
2025-09-11 Provide medically-related social services to help each resident achieve the highest possible quality of life.
Quality of Life and Care Deficiencies · tag F0745
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-10-15
2025-09-11 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · tag F0842
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-10-15
2025-06-18
complaint survey
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-07-18
2025-06-18
complaint survey
Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · tag F0760
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-07-18
2025-06-18
complaint survey
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · tag F0580
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-18
2025-03-26
complaint survey
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600
D No actual harm, with potential for more than minimal harm; isolated Past Non-Compliance
2025-03-25
2025-03-26
complaint survey
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-04-30
2025-03-05
complaint survey
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686
G Actual harm that is not immediate jeopardy; isolated Past Non-Compliance
2025-03-04
2025-03-05
complaint survey
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · tag F0658
D No actual harm, with potential for more than minimal harm; isolated Past Non-Compliance
2025-03-04
2025-03-05
complaint survey
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Quality of Life and Care Deficiencies · tag F0678
D No actual harm, with potential for more than minimal harm; isolated Past Non-Compliance
2025-03-04
2024-08-06
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-08-22
2024-07-10
complaint survey
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2024-08-03
2024-07-10
complaint survey
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686
G Actual harm that is not immediate jeopardy; isolated Past Non-Compliance
2024-06-21
2024-05-15 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies · tag F0690
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2024-06-13
2024-05-15 Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · tag F0658
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-06-13
2024-05-15 Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · tag F0760
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-06-13
2024-05-15 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.
Pharmacy Service Deficiencies · tag F0761
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-06-13
2024-05-15 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-06-13

Fines and payment denials

DatePenaltyAmount
2025-11-06Fine$70,720
2025-09-11Fine$42,705
2025-03-05Fine$8,112
2024-07-10Fine$11,333
2024-07-10Fine$8,018
2024-05-15Fine$12,695

Who owns and runs it

Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.

NameRoleShareSince
Doros Generation Trust U/A/D 1/3/12
Organization
5% or greater direct ownership interest43%2019-07-01
Gpn Family Trust U/A/D 4/28/08
Organization
5% or greater direct ownership interest43%2019-07-01
Oakway Operations LLC
Organization
5% or greater direct ownership interest15%2019-07-01
Arrowhead Sd Property Holdings, LLC
Organization
5% or greater security interest2019-07-01
Truist Bank
Organization
5% or greater security interest2022-04-01
Arrowhead Sd Property Holdings, LLC
Organization
adp of the snf2019-07-01
Doros Generation Trust U/A/D 1/3/12
Organization
adp of the snf2019-07-01
Gpn Family Trust U/A/D 4/28/08
Organization
adp of the snf2019-07-01
Legacy Healthcare Financial Services LLC
Organization
adp of the snf2025-11-10
Rsm US LLP
Organization
adp of the snf2024-01-01
Legacy Healthcare Financial Services LLC
Organization
operational/managerial control2019-07-01
Truist Bank
Organization
operational/managerial control2022-04-01
Martin, Sharon
Individual
adp of the snf2023-04-09
Ptacek, Travis
Individual
adp of the snf2025-01-01
Rajchenbach, Chaim
Individual
adp of the snf2019-07-01
Shabat, Menachem
Individual
adp of the snf2019-07-01
Rajchenbach, Chaim
Individual
managing control - governing body2019-07-01
Shabat, Menachem
Individual
managing control - governing body2019-07-01
Martin, Sharon
Individual
operational/managerial control2023-04-09
Ptacek, Travis
Individual
operational/managerial control2025-01-01
Rajchenbach, Chaim
Individual
operational/managerial control2019-07-01
Shabat, Menachem
Individual
operational/managerial control2019-07-01

What changed

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Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Pennington County.