Cycle 1
Health 2025-09-11 · Fire 2025-09-11
28 health deficiencies
Top issue: Quality of Life and Care (13 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Rapid City, SD
Avantara Arrowhead
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $40,014 in total fines with 28 recent health deficiencies
2500 Arrowhead Dr, Rapid City, SD
(605) 348-0285
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
65
Certified beds
Average residents
60
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Legacy Healthcare
Operator or chain grouping
Approved since
1991-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
90 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 quality stars
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
0.74
Registered nurse staffing · state 0.80 · national 0.68
LPN hours / resident day
0.57
Licensed practical nurse staffing · state 0.49 · national 0.87
Aide hours / resident day
1.97
Nurse aide staffing · state 2.61 · national 2.35
Total nurse hours
3.27
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.31
RN + LPN hours · state 1.28 · national 1.54
Weekend hours
2.85
Weekend nurse staffing · state 3.32 · national 3.43
Weekend RN hours
0.53
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.65
CMS adjusted RN staffing hours
Adjusted total hours
2.89
CMS adjusted total nurse staffing hours
Case-mix index
1.55
Higher values indicate more complex resident acuity
RN turnover
53%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
62%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,789
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.12
Composite VBP score used to determine payment impact.
Payment multiplier
0.9821
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.60
Baseline 23.77% · Performance 19.66% · Measure score 5.60 · Achievement 3.83 · Improvement 5.60
Healthcare-associated infections
2.05
Baseline 9.23% · Performance 8.15% · Measure score 2.05 · Achievement 0 · Improvement 2.05
Total nurse turnover
0
Baseline 55.10% · Performance 73.97% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.14 hours · Performance 3.08 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.76% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 48 · Observed rate 12.5% · Lower 95% interval 6.95% |
| Discharge to community | 50.24% |
50.57%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 29 · Observed rate 41.38% · Lower 95% interval 34.72% |
| Medicare spending per beneficiary | 1.52 |
1.02
0.5 pts worse
|
|
| Drug regimen review with follow-up | 95.45% |
95.27%
0.2 pts better
|
Numerator 42 · Denominator 44 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 44 |
| Discharge self-care score | 20% |
53.69%
33.7 pts worse
|
Numerator 6 · Denominator 30 |
| Discharge mobility score | 3.33% |
50.94%
47.6 pts worse
|
Numerator 1 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 44 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.15% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 29 · Observed rate 13.79% · Lower 95% interval 4.03% |
| Staff COVID-19 vaccination coverage | 15.79% |
8.2%
7.6 pts better
|
Numerator 12 · Denominator 76 |
| Staff flu vaccination coverage | 39.25% |
42%
2.8 pts worse
|
Numerator 42 · Denominator 107 |
| Discharge function score | 20% |
56.45%
36.5 pts worse
|
Numerator 6 · Denominator 30 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 48.28% |
25.2%
23.1 pts better
|
Numerator 14 · Denominator 29 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.5
0.2 pts worse
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 2.1 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.9
0.8 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.2 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.9% |
95.4%
6.5 pts worse
|
93.4%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 96.2% · Q2 98.3% · Q3 81.8% · Q4 80.3% · 4Q avg 88.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.3% |
96.9%
6.6 pts worse
|
95.5%
5.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
5.1%
5.1 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.0% |
4.6%
6.4 pts worse
|
11.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 13.7% · Q4 25.0% · 4Q avg 11.0% |
| Percentage of long-stay residents who lose too much weight | 6.2% |
5.5%
0.7 pts worse
|
5.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 0.0% · Q3 12.5% · Q4 7.7% · 4Q avg 6.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.7% |
17.8%
5.9 pts worse
|
19.6%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.1% · Q2 25.5% · Q3 23.1% · Q4 19.6% · 4Q avg 23.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 35.8% |
25.1%
10.7 pts worse
|
16.7%
19.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.4% · Q2 35.5% · Q3 40.6% · Q4 31.6% · 4Q avg 35.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
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 | 26.5% |
21.3%
5.2 pts worse
|
16.3%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.0% |
21.6%
1.6 pts better
|
14.9%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 22.4% · Q3 28.3% · Q4 15.7% · 4Q avg 20.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.0%
2 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.3% |
3.3%
2 pts worse
|
1.7%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 3.8% · Q3 5.9% · Q4 8.8% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 34.2% |
25.8%
8.4 pts worse
|
19.8%
14.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.6% · Q2 22.9% · Q3 38.1% · Q4 43.8% · 4Q avg 34.2% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
4.6%
1.2 pts worse
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 6.0% · Q3 5.1% · Q4 6.3% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 37.7% |
83.2%
45.5 pts worse
|
81.7%
44 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 37.8% · Q2 39.4% · Q3 42.9% · Q4 31.2% · 4Q avg 37.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.3% |
11.7%
3.6 pts worse
|
12.0%
3.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.3% · Observed 16.0% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.7%
About the same
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 48.5% |
78.2%
29.7 pts worse
|
79.7%
31.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 48.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.7% |
21.5%
5.8 pts better
|
23.9%
8.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.7% · Observed 16.0% · Expected 24.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-15 · Fire 2024-05-15
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-03-09 · Fire 2023-03-09
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-05-15
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-06-11
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-10
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.
Not marked corrected
D · Potential for more than minimal harm
2025-12-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Not marked corrected
D · Potential for more than minimal harm
2025-12-10
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Not marked corrected
G · Actual harm
2025-11-06
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 2025-12-06
G · Actual harm
2025-09-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-15
G · Actual harm
2025-09-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-10-15
G · Actual harm
2025-09-11
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 2025-10-15
G · Actual harm
2025-09-11
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-10-15
E · Potential for more than minimal harm
2025-09-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-10-15
E · Potential for more than minimal harm
2025-09-11
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-10-15
E · Potential for more than minimal harm
2025-09-11
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 2025-10-15
E · Potential for more than minimal harm
2025-09-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-11
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-11
F578 · Resident Rights Deficiencies
Health
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 2025-10-15
D · Potential for more than minimal harm
2025-09-11
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-11
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-11
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-11
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-11
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-11
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-10-15
E · Potential for more than minimal harm
2025-06-18
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-07-18
E · Potential for more than minimal harm
2025-06-18
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-06-18
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 2025-07-18
D · Potential for more than minimal harm
2025-03-26
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-03-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-30
G · Actual harm
2025-03-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-04
D · Potential for more than minimal harm
2025-03-05
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-03-04
D · Potential for more than minimal harm
2025-03-05
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 2025-03-04
D · Potential for more than minimal harm
2024-08-06
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 2024-08-22
G · Actual harm
2024-07-10
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-08-03
G · Actual harm
2024-07-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-06-21
G · Actual harm
2024-05-15
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-06-13
D · Potential for more than minimal harm
2024-05-15
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-06-13
D · Potential for more than minimal harm
2024-05-15
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-06-13
D · Potential for more than minimal harm
2024-05-15
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 2024-06-13
D · Potential for more than minimal harm
2024-05-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-13
D · Potential for more than minimal harm
2023-03-09
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-04-11
Penalties and ownership
What sits behind the stars
$7,968
2025-03-05
Fine
Fine · fine $7,968
Fine
$8,018
2024-07-10
Fine
Fine · fine $8,018
Fine
$11,333
2024-07-10
Fine
Fine · fine $11,333
Fine
$12,695
2024-05-15
Fine
Fine · fine $12,695
Fine
Ownership
Chaim Rajchenbach Descendants Tr Ua 04282008
5% Or Greater Direct Ownership Interest · Organization
Doros Generation Trust U/A/D 1/3/12
5% Or Greater Direct Ownership Interest · Organization
Oakway Operations LLC
5% Or Greater Direct Ownership Interest · Organization
Arrowhead Sd Property Holdings, LLC
5% Or Greater Security Interest · Organization
Legacy Healthcare Financial Services LLC
Operational/Managerial Control · Organization
Martin, Sharon
Operational/Managerial Control · Individual
Ptacek, Travis
Operational/Managerial Control · Individual
Rajchenbach, Chaim
Operational/Managerial Control · Individual
Shabat, Menachem
Operational/Managerial Control · Individual
Truist Bank
Operational/Managerial Control · Organization
Truist Bank
5% Or Greater Security Interest · Organization
Nearby options
Other facilities in reach
#1
Clarkson Health Care
Rapid City, SD
5-star overall rating with 5-star inspections with 3 recent health deficiencies
#2
Avantara Mountain View
Rapid City, SD
3-star overall rating with 3-star inspections with $9,318 in total fines with 5 recent health deficiencies
#3
Avantara Saint Cloud
Rapid City, SD
1-star overall rating with 2-star inspections with abuse icon flag with $11,408 in total fines with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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